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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803970
Report Date: 09/02/2022
Date Signed: 09/02/2022 11:46:25 AM

Document Has Been Signed on 09/02/2022 11:46 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:JESSIE'S PLACE, LLCFACILITY NUMBER:
486803970
ADMINISTRATOR:MURPHY, TINIKAFACILITY TYPE:
735
ADDRESS:122 CALIFORNIA ST.TELEPHONE:
(707) 731-1715
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 2CENSUS: 0DATE:
09/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Tinika Murphy, LicenseeTIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and was greeted by Licensee, Tinika Murphy. The facility currently has 0 clients in care but Licensee is in the process of becoming vendorized through North Bay Regional Center. Licensee will be notifying CCLD of vendorizing status and admission of clients once completed.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Licensee; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher were tested and found to be last charged on 4/22/2021 at the time of visit. Licensee agreed to acquire servicing from Fire Inspector and provide documentation. Both smoke detectors and carbon monoxide detectors were tested found to be functioning. A storage shed located in the backyard containing yard supplies was found to be locked and secured.

There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins and cleaning supplies are stored in locked cabinets in the facility kitchen and storage room. There was a supply of cleaners, hygiene products and paper products available for clients. All client’s bedrooms have lighting & appropriate furnishings. Medications and records will be located in secured cabinets located in facility office. Water at faucets accessible to clients measured between 128.6 and 129.3 degrees F which is not within Title 22 Regulation between 105 and 120 degrees F. Licensee agrees to adjust water heater and conduct water temperature test to ensure compliance.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: JESSIE'S PLACE, LLC
FACILITY NUMBER: 486803970
VISIT DATE: 09/02/2022
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Infection Control:
Facility is to submit an Infection Control Plan to CCLD for review. Posters will also be placed at the front door, common areas and restroom promoting COVID safety protocols. Facility has a station at main entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff. There are no concerns of PPE and sanitation supply shortages. All staff have been vaccinated with no clients in care at this time. Facility holds records for staff and clients to be screened for temperature and symptoms on a daily basis or based on change of condition.

LPA requested the following documents be sent to CCL by COB 9/16/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance

LPA issued several Technical Assistance/Violation notes for corrections. No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022
LIC809 (FAS) - (06/04)
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